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Applicati res 1 I Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> ' 1 APPLICATION
<br /> jDCrNL(For Non-Transferable, Revocable, and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Appl in 1s hereby made to carry on businessinlhe jurisdictional area of the San Joaquin Local Health D'strict
<br /> wBusiness Name (DBA) __ ddress �•�� r mr. 4n—o +
<br /> z Owner ddress 4
<br /> a s:, : w y 3
<br /> J Firm Partners, Addresses and Telephone Numbers
<br /> E Business Telephone No. -Emergency Telephone No. 4 V a
<br /> Contractor Licence NO. .
<br /> Applicants Name (Print) y Title l�1EHl� _ y Da
<br /> Please check Applicable Category (1-7)and,Fill in the Required Information
<br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) }
<br /> For July 1, - June 30, 19 -- Disposal Sites
<br /> Description(Make/Yr., Color) r
<br /> Serial No. CAL. License No. CAL_:License Renewal No.
<br /> Capacity Gal.,Weights & Measures No. r ll
<br /> Equipment Parking Address A
<br /> 2. ❑ PUMPER YARD �. %
<br /> For July 1, June 30, 19
<br /> No, of Vehicles Stored f t )
<br /> No. of Chemical Toilets Stored
<br /> 3. ❑ 'PERCOLATION TEST '
<br /> R.S. or R.C.E. Name R.S. or R.C.E. No.
<br /> Tetcation Test Date/Time I.
<br /> 4ANITATION PERMIT
<br /> Job Address/Location h
<br /> Owner Address
<br /> ❑ SEPTIC TANK ❑ CESSPOOL AKLACHING FIELD jWSEEPAGE PIT ❑ PACKAGF,PLANT � 6
<br /> PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER` g�{]� jam]N '
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <r :� /" �i.} 1�S
<br /> Type Construction Disposal Site
<br /> No. of Units Equipment Storage/Cleaning Location(s)
<br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19
<br /> Operator Name Where Certified 'f -
<br /> Plant Location
<br /> Plant Capacity No. Units Served N
<br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 ) •'' {
<br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ; =
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> Home awh o-iicensedattAr„'Qsr naturoeerteitstt3'iran+��is�ir� t±sr,;:[€,a';Mtt,e,Gl-.`nrman�0c,f;!+neve k nrnhichtftispermiti,is;lae .ishaflna;erfplayany pCrs
<br /> is sue11 man ,.1;s tv t�eearile stlb�ac�io�rurkrea ,p�r:�atian: �+, � .;tic �'�� 'j a I �:.
<br /> Contractor's IifflrlQ-co Fljt-CRII!TII Lt iY 1Fj Cart;:ieln r foc 6v r�. 't t:, rtf r^I;a n, peri�1r.1,.lrce Mti wine t1or rlhfi:h this permit is issued i shall 1
<br /> Qrnpioy persons sutiject to tiiart(Tllan'S
<br /> I hereby certify that I have repared this application and that the work will be done in acco�danclti with;5an Joaquin County i
<br /> ordinances, state laws, a and regulat ns of th a Jo uin al th District.
<br /> APPLICANT'S SIGNATURE X10� s{'
<br /> t FOR DEPARTMENT USE ONLY - !
<br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ___❑ PER SITE E ❑ EACH k ❑ Anuary 1 &;Received By January 31 ❑ July 1 &Received By July 31 - .
<br /> BILLING REMITTANCE "� $ , REMIT
<br /> BASE EXPLANATION s AMOUNT DUE CHECKED
<br /> DATE DATE • 1 REAITTED * i AMOUNT 1
<br /> L
<br /> FEE
<br /> LESS
<br /> PRORATION
<br /> PLUS
<br /> PENALTY
<br /> —OTHER
<br /> p t^g,._.. .-.� 4,Yv.I�i -a,.�..� ,� a °b.C-� '� `'• ��'
<br /> OTHER ... ”
<br /> Received by tate Receipt No, Permit No I Iss4ance a Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520,
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